Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Are there particular concerns related to the use of B-cell depletion therapies such as rituximab for rheumatic disease during the COVID-19 pandemic?
The attendant depletion of CD20+ B cells associated with treatment with rituximab likely results in impaired development of host immunity to previously unrecognized microbial pathogens. This has, therefore, been of concern in the context of the Covid-19 pandemic due to potential greater adverse outc...
What is the biologic of choice in a patient with RA and history of non-melanoma skin cancer?
We have long known that patients treated with TNF inhibitors (TNFi) have a higher risk of developing non-melanoma skin cancers. For this reason, all patients prescribed these drugs should undergo annual full-body dermatology skin exams. If this recommendation is followed, there should be no contrain...
What are the benefits of sending HLA B27 genotype over HLA B27 antigen when evaluating for spondyloarthritis?
HLA-B27 is strongly associated with ankylosing spondylitis (AS) which is an inflammatory rheumatic disease that affects the spine, the sacroilliac joints, and peripheral joints. It is also associated with other diseases like acute anterior uveitis, inflammatory bowel disease, or psoriasis. HLA-B27 t...
How do you approach patients with overlapping features of PMR and seronegative RA?
To me, this is the same as saying how to treat large and small joint rheumatoid arthritis in the same patient. For me, the difference is largely in the use of steroids. I have used much less steroids in my patients who I believe to have small joint seronegative rheumatoid arthritis, initiating a DMA...
Are you recommending the mRNA COVID-19 vaccines to your patients with immune mediated inflammatory diseases?
This is THE question at the moment for providers of patients with immune mediated inflammatory diseases. For now, we are merely extrapolating as patients with active IMIDS were censored from trials (Pfizer & Moderna). Organizations like the American College of Rheumatology are moving quickly to clos...
What are specific treatment considerations for dactylitis- or enthesitis-predominant AxSpa/PsA?
Treating these manifestations of peripheral SpA is challenging. It is always important to have a baseline assessment of the liver and kidney function as well as other relevant labs prior to starting therapeutic treatments. In addition, careful assessment and consideration to comorbidities should be ...
How useful are anti-ribosomal P antibodies in the evaluation for SLE psychosis?
I do not think they are very useful at all. This may be a controversial opinion, but I think they should be largely retired from clinical practice. Though somewhat dated, an excellent meta analysis (Karassa et al., PMID 16385548) on this question concluded the following: "This meta-analysis demonstr...
Is there evidence that either ASDAS or BASDAI is superior for measuring clinical outcomes in axial spondyloarthritis?
BASDAI and ASDAS are validated measures of AS disease activity and are used simultaneously in clinical trials. BASDAI (Bath Ankylosing Spondylitis Disease Activity Index)1 exhibits good reliability, sensitivity to change in response to intervention, has 6 questions (fatigue, back pain/hip pain, peri...
Is a comprehensive physical exam with vital signs warranted for routine follow-up visits in well-controlled uncomplicated RA patients?
This is an important question for which we don't have an evidence-based answer yet, but it is likely that our practice will change with these new guidelines, and with the expansion of telemedicine. I think we cannot have a one size fits all recommendation. Many factors may influence the need for a f...
Is there a role for measuring hydroxychloroquine blood levels in clinical practice?
This is being actively investigated by a number of groups around the world, with no final consensus, but the groups in France have studied this the longest, and published the most, to date. The major outcome has been that some (quite a few) patients had very low levels, who admitted on careful quest...